Whether you have just begun exploring treatment options or have already decided to
undergo hip replacement surgery, this information will help you understand the benefits
and limitations of total hip replacement. This article describes how a normal hip
works, the causes of hip pain, what to expect from hip replacement surgery, and what
exercises and activities will help restore your mobility and strength, and enable
you to return to everyday activities.

If your hip has been damaged by arthritis, a fracture, or other conditions, common
activities such as walking or getting in and out of a chair may be painful and difficult.
Your hip may be stiff, and it may be hard to put on your shoes and socks. You may
even feel uncomfortable while resting.

If medications, changes in your everyday activities, and the use of walking supports
do not adequately help your symptoms, you may consider hip replacement surgery. Hip
replacement surgery is a safe and effective procedure that can relieve your pain,
increase motion, and help you get back to enjoying normal, everyday activities.

First performed in 1960, hip replacement surgery is one of the most successful operations
in all of medicine. Since 1960, improvements in joint replacement surgical techniques
and technology have greatly increased the effectiveness of total hip replacement.
According to the Agency for Healthcare Research and Quality, more than 300,000 total
hip replacements are performed each year in the United States.

Anatomy

The hip is one of the body's largest joints. It is a ball-and-socket joint. The socket
is formed by the acetabulum, which is part of the large pelvis bone. The ball is the
femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth
tissue that cushions the ends of the bones and enables them to move easily.

A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip,
this membrane makes a small amount of fluid that lubricates the cartilage and eliminates
almost all friction during hip movement.

Bands of tissue called ligaments (the hip capsule) connect the ball to the socket
and provide stability to the joint.

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis,
rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

Osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually occurs in people
50 years of age and older and often in individuals with a family history of arthritis.
The cartilage cushioning the bones of the hip wears away. The bones then rub against
each other, causing hip pain and stiffness. Osteoarthritis may also be caused or
accelerated by subtle irregularities in how the hip developed in childhood.

Rheumatoid arthritis. This is an autoimmune disease in which the synovial membrane becomes inflamed and
thickened. This chronic inflammation can damage the cartilage, leading to pain and
stiffness. Rheumatoid arthritis is the most common type of a group of disorders termed
"inflammatory arthritis."

Post-traumatic arthritis. This can follow a serious hip injury or fracture. The cartilage may become damaged
and lead to hip pain and stiffness over time.

Avascular necrosis. An injury to the hip, such as a dislocation or fracture, may limit the blood supply
to the femoral head. This is called avascular necrosis (also commonly referred to
as "osteonecrosis"). The lack of blood may cause the surface of the bone to collapse,
and arthritis will result. Some diseases can also cause avascular necrosis.

Childhood hip disease. Some infants and children have hip problems. Even though the problems are successfully
treated during childhood, they may still cause arthritis later on in life. This happens
because the hip may not grow normally, and the joint surfaces are affected.

The decision to have hip replacement surgery should be a cooperative one made by you,
your family, your primary care doctor, and your orthopaedic surgeon. The process of
making this decision typically begins with a referral by your doctor to an orthopaedic
surgeon for an initial evaluation.

Candidates for Surgery

There are no absolute age or weight restrictions for total hip replacements.

Recommendations for surgery are based on a patient's pain and disability, not age.
Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic
surgeons evaluate patients individually. Total hip replacements have been performed
successfully at all ages, from the young teenager with juvenile arthritis to the elderly
patient with degenerative arthritis.

When Surgery Is Recommended

There are several reasons why your doctor may recommend hip replacement surgery. People
who benefit from hip replacement surgery often have:

An evaluation with an orthopaedic surgeon consists of several components.

Medical history. Your orthopaedic surgeon will gather information about your general health and ask
questions about the extent of your hip pain and how it affects your ability to perform
everyday activities.

Physical examination. This will assess hip mobility, strength, and alignment.

X-rays. These images help to determine the extent of damage or deformity in your hip.

Other tests. Occasionally other tests, such as a magnetic resonance imaging (MRI) scan, may be
needed to determine the condition of the bone and soft tissues of your hip.

(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy
cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space.

This x-ray shows a large bone spur that has developed on the ball of an arthritic
hip.

Talk With Your Doctor

Your orthopaedic surgeon will review the results of your evaluation with you and discuss
whether hip replacement surgery is the best method to relieve your pain and improve
your mobility. Other treatment options — such as medications, physical therapy, or
other types of surgery — also may be considered.

In addition, your orthopaedic surgeon will explain the potential risks and complications
of hip replacement surgery, including those related to the surgery itself and those
that can occur over time after your surgery.

Never hesitate to ask your doctor questions when you do not understand. The more you
know, the better you will be able to manage the changes that hip replacement surgery
will make in your life.

Realistic Expectations

An important factor in deciding whether to have hip replacement surgery is understanding
what the procedure can and cannot do. Most people who undergo hip replacement surgery
experience a dramatic reduction of hip pain and a significant improvement in their
ability to perform the common activities of daily living.

With normal use and activity, the material between the head and the socket of every
hip replacement implant begins to wear. Excessive activity or being overweight may
speed up this normal wear and cause the hip replacement to loosen and become painful.
Therefore, most surgeons advise against high-impact activities such as running, jogging,
jumping, or other high-impact sports.

Medical Evaluation

If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you
to have a complete physical examination by your primary care doctor before your surgical
procedure. This is needed to make sure you are healthy enough to have the surgery
and complete the recovery process. Many patients with chronic medical conditions,
like heart disease, may also be evaluated by a specialist, such a cardiologist, before
the surgery.

Tests

Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest
x-rays, may be needed to help plan your surgery.

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either
is present, contact your orthopaedic surgeon for treatment to improve your skin before
surgery.

Blood Donations

You may be advised to donate your own blood prior to surgery. It will be stored in
the event you need blood after surgery.

Medications

Tell your orthopaedic surgeon about the medications you are taking. He or she or your
primary care doctor will advise you which medications you should stop taking and which
you can continue to take before surgery.

Weight Loss

If you are overweight, your doctor may ask you to lose some weight before surgery
to minimize the stress on your new hip and possibly decrease the risks of surgery.

Dental Evaluation

Although infections after hip replacement are not common, an infection can occur if
bacteria enter your bloodstream. Because bacteria can enter the bloodstream during
dental procedures, major dental procedures (such as tooth extractions and periodontal
work) should be completed before your hip replacement surgery. Routine cleaning of
your teeth should be delayed for several weeks after surgery.

Urinary Evaluation

Individuals with a history of recent or frequent urinary infections should have a
urological evaluation before surgery. Older men with prostate disease should consider
completing required treatment before having surgery.

Social Planning

Although you will be able to walk with crutches or a walker soon after surgery, you
will need some help for several weeks with such tasks as cooking, shopping, bathing,
and laundry.

If you live alone, your orthopaedic surgeon's office, a social worker, or a discharge
planner at the hospital can help you make advance arrangements to have someone assist
you at your home. A short stay in an extended care facility during your recovery after
surgery also may be arranged.

Home Planning

Several modifications can make your home easier to navigate during your recovery.
The following items may help with daily activities:

Securely fastened safety bars or handrails in your shower or bath

Secure handrails along all stairways

A stable chair for your early recovery with a firm seat cushion (that allows your
knees to remain lower than your hips), a firm back, and two arms

A raised toilet seat

A stable shower bench or chair for bathing

A long-handled sponge and shower hose

A dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking
off shoes and socks without excessively bending your new hip

A reacher that will allow you to grab objects without excessive bending of your hips

Firm pillows for your chairs, sofas, and car that enable you to sit with your knees
lower than your hips

Removal of all loose carpets and electrical cords from the areas where you walk in
your home

Set up a "recovery center" where you will spend most of your time. Things like the
phone, television remote control, reading materials, and medications should all be
within reach.

You will most likely be admitted to the hospital on the day of your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. The most
common types of anesthesia are general anesthesia (you are put to sleep) or spinal,
epidural, or regional nerve block anesthesia (you are awake but your body is numb
from the waist down). The anesthesia team, with your input, will determine which type
of anesthesia will be best for you.

Implant Components

Many different types of designs and materials are currently used in artificial hip
joints. All of them consist of two basic components: the ball component (made of highly
polished strong metal or ceramic material) and the socket component (a durable cup
of plastic, ceramic or metal, which may have an outer metal shell).

The prosthetic components may be "press fit" into the bone to allow your bone to grow
onto the components or they may be cemented into place. The decision to press fit
or to cement the components is based on a number of factors, such as the quality and
strength of your bone. A combination of a cemented stem and a non-cemented socket
may also be used.

Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.

(Left) A standard non-cemented femoral component. (Center) A close-up of this component
showing the porous surface for bone ingrowth. (Right) The femoral component and the acetabular component working together.

(Left) The acetabular component shows the plastic (polyethylene) liner inside the metal
shell. (Right) The porous surface of this acetabular component allows for bone ingrowth. The holes
around the cup are used if screws are needed to hold the cup in place.

Procedure

The surgical procedure takes a few hours. Your orthopaedic surgeon will remove the
damaged cartilage and bone and then position new metal, plastic, or ceramic implants
to restore the alignment and function of your hip.

X-rays before and after total hip replacement. In this case, non-cemented components
were used.

After surgery, you will be moved to the recovery room where you will remain for several
hours while your recovery from anesthesia is monitored. After you wake up, you will
be taken to your hospital room.

You will most likely stay in the hospital for a few days. To protect your hip during
early recovery, a positioning splint, such as a foam pillow placed between your legs,
may be used.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process.
Your doctor and nurses will work to reduce your pain, which can help you recover from
surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types
of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory
drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these
medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic
and can be addictive. Opioid dependency and overdose has become a critical public
health issue in the U.S. It is important to use opioids only as directed by your doctor.
As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if
your pain has not begun to improve within a few days of your surgery.

Physical Therapy

Walking and light activity are important to your recovery. Most patients who undergo
total hip replacement begin standing and walking with the help of a walking support
and a physical therapist the day after surgery. In some cases, patients begin standing
and walking on the actual day of surgery. The physical therapist will teach you specific
exercises to strengthen your hip and restore movement for walking and other normal
daily activities.

Preventing Pneumonia

It is common for patients to have shallow breathing in the early postoperative period.
This is usually due to the effects of anesthesia, pain medications, and increased
time spent in bed. This shallow breathing can lead to a partial collapse of the lungs
(termed "atelectasis") which can make patients susceptible to pneumonia. To help prevent
this, it is important to take frequent deep breaths. Your nurse may provide a simple
breathing apparatus called a spirometer to encourage you to take deep breaths.

The success of your surgery will depend in large measure on how well you follow your
orthopaedic surgeon's instructions regarding home care during the first few weeks
after surgery.

Wound Care

You may have stitches or staples running along your wound or a suture beneath your
skin. The stitches or staples will be removed approximately 2 weeks after surgery.

Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue
to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet,
often with an iron supplement, is important to promote proper tissue healing and restore
muscle strength. Be sure to drink plenty of fluids.

Activity

Exercise is a critical component of home care, particularly during the first few weeks
after surgery. You should be able to resume most normal light activities of daily
living within 3 to 6 weeks following surgery. Some discomfort with activity and at
night is common for several weeks.

Your activity program should include:

A graduated walking program to slowly increase your mobility, initially in your home
and later outside

Resuming other normal household activities, such as sitting, standing, and climbing
stairs

Specific exercises several times a day to restore movement and strengthen your hip.
You probably will be able to perform the exercises without help, but you may have
a physical therapist help you at home or in a therapy center the first few weeks after
surgery

The complication rate following hip replacement surgery is low. Serious complications,
such as joint infection, occur in less than 2% of patients. Major medical complications,
such as heart attack or stroke, occur even less frequently. However, chronic illnesses
may increase the potential for complications. Although uncommon, when these complications
occur they can prolong or limit full recovery.

Infection

Infection may occur superficially in the wound or deep around the prosthesis. It may
happen while in the hospital or after you go home. It may even occur years later.

Minor infections of the wound are generally treated with antibiotics. Major or deep
infections may require more surgery and removal of the prosthesis. Any infection in
your body can spread to your joint replacement.

Blood Clots

Blood clots may form in the leg veins or pelvis.

Blood clots in the leg veins or pelvis are one of the most common complications of
hip replacement surgery. These clots can be life-threatening if they break free and
travel to your lungs. Your orthopaedic surgeon will outline a prevention program which
may include blood thinning medications, support hose, inflatable leg coverings, ankle
pump exercises, and early mobilization.

Leg-length Inequality

Sometimes after a hip replacement, one leg may feel longer or shorter than the other.
Your orthopaedic surgeon will make every effort to make your leg lengths even, but
may lengthen or shorten your leg slightly in order to maximize the stability and biomechanics
of the hip. Some patients may feel more comfortable with a shoe lift after surgery.

Dislocation

This occurs when the ball comes out of the socket. The risk for dislocation is greatest
in the first few months after surgery while the tissues are healing. Dislocation is
uncommon. If the ball does come out of the socket, a closed reduction usually can
put it back into place without the need for more surgery. In situations in which
the hip continues to dislocate, further surgery may be necessary.

Hip implant dislocation.

Loosening and Implant Wear

Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday
activity. It can also result from a biologic thinning of the bone called osteolysis.
If loosening is painful, a second surgery called a revision may be necessary.

Other Complications

Nerve and blood vessel injury, bleeding, fracture, and stiffness can occur. In a small
number of patients, some pain can continue or new pain can occur after surgery.

Recognizing the Signs of a Blood Clot

Follow your orthopaedic surgeon's instructions carefully to reduce the risk of blood
clots developing during the first several weeks of your recovery. He or she may recommend
that you continue taking the blood thinning medication you started in the hospital.
Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

Sudden shortness of breath

Sudden onset of chest pain

Localized chest pain with coughing

Preventing Infection

A common cause of infection following hip replacement surgery is from bacteria that
enter the bloodstream during dental procedures, urinary tract infections, or skin
infections.

Following surgery, patients with certain risk factors may need to take antibiotics
prior to dental work, including dental cleanings, or before any surgical procedure
that could allow bacteria to enter your bloodstream. Your orthopaedic surgeon will
discuss with you whether taking preventive antibiotics before dental procedures is
needed in your situation.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible
hip replacement infection:

Persistent fever (higher than 100°F orally)

Shaking chills

Increasing redness, tenderness, or swelling of the hip wound

Drainage from the hip wound

Increasing hip pain with both activity and rest

Avoiding Falls

A fall during the first few weeks after surgery can damage your new hip and may result
in a need for more surgery. Stairs are a particular hazard until your hip is strong
and mobile. You should use a cane, crutches, a walker, or handrails or have someone
help you until you improve your balance, flexibility, and strength.

Your orthopaedic surgeon and physical therapist will help you decide which assistive
aides will be required following surgery, and when those aides can safely be discontinued.

Other Precautions

To assure proper recovery and prevent dislocation of the prosthesis, you may be asked
to take special precautions when sitting, bending, or sleeping — usually for the first
6 weeks after surgery. These precautions will vary from patient to patient, depending
on the surgical approach your surgeon used to perform your hip replacement.

Prior to discharge from the hospital, your surgeon and physical therapist will provide
you with any specific precautions you should follow.

How Your New Hip Is Different

You may feel some numbness in the skin around your incision. You also may feel some
stiffness, particularly with excessive bending. These differences often diminish with
time, and most patients find these are minor compared with the pain and limited function
they experienced prior to surgery.

Your new hip may activate metal detectors required for security in airports and some
buildings. Tell the security agent about your hip replacement if the alarm is activated.
You may ask your orthopaedic surgeon for a card confirming that you have an artificial
hip.

Protecting Your Hip Replacement

There are many things you can do to protect your hip replacement and extend the life
of your hip implant.

Participate in a regular light exercise program to maintain proper strength and mobility
of your new hip.

Take special precautions to avoid falls and injuries. If you break a bone in your
leg, you may require more surgery.

Make sure your dentist knows that you have a hip replacement. Talk with your orthopaedic
surgeon about whether you need to take antibiotics prior to dental procedures.

See your orthopaedic surgeon periodically for routine follow-up examinations and x-rays,
even if your hip replacement seems to be doing fine.

AAOS does not endorse any treatments, procedures, products, or physicians referenced
herein. This information is provided as an educational service and is not intended
to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance
should consult his or her orthopaedic surgeon, or locate one in your area through
the AAOS "Find an Orthopaedist" program on this website.